- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $3,467.37
| Professional | | $1,737.80 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,762.47 / $26,915.35
| Facility | | $3,801.89 | $7,762.47 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $6,606.93
| Professional | | $2,818.38 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,309.57 / $15,135.61
| Facility | | $4,466.84 | $6,309.57 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,370.32 / $8,128.31
| Professional | | $3,548.13 | $5,370.32 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,025.60 / $11,748.98
| Facility | | $4,897.79 | $6,025.60 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,570.88 / $6,760.83
| Professional | | $3,388.44 | $4,570.88 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $5,248.07
| Facility | | $2,137.96 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,630.78 / $7,585.78
| Professional | | $2,187.76 | $3,630.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $7,413.10
| Professional | | $2,344.23 | $3,715.35 | $7,413.10 |